Optimizing genome-wide mutation analysis of chromosomes and genes

ABSTRACT

A method of genome-wide testing of gene copy number at the genetically most important loci to determine whether the gene and/or its selected larger surrounding chromosome region is rearranged to result in an unbalanced abnormality in one or more subjects, said method including selecting multiple gene loci of said DNAs to be examined in said test, conducting said test, and comparing the number of copies at each locus tested by quantification of total gene target number to determine the relative, number of each polymorphic sequence detected to assure that each important tested sequence is distinguished from the other alleles at the same locus. A method of detecting the highest number of abnormal patients possible based upon the number of test sites available in a protocol including selecting the most common genetic disease-causing mutations in a population by frequency, selecting and identifying the most common mutations in each by frequencies, multiplying the two frequencies together to get a frequency product which is the frequency of each mutation in the population, and ordering the frequency products beginning with the most common to prioritize which are the most common to detect the largest number of genetic abnormalities possible per test. Depending upon the stage of the life cycle, both of the methods can be done together or in sequence.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the priority of U.S. Provisional Application Ser. No. 60/161857 filed Oct. 27, 1999 and U.S. Provisional Application Ser. No. 60/317,007 filed Sep. 4, 2001 entitled “Genome-Wide Aneuploid Analysis of Chromosomes and Genes” by QPCR the whole of which is hereby incorporated by reference herein.

BACKGROUND OF THE INVENTION

Since the early 1970's when routine chromosome banding was developed, Giemsa-banded chromosome analysis has been applied to diagnosing chromosome abnormalities in fetuses, abnormal children, adolescents, and adults, in both normal and neoplastic tissues. Giemsa-banded karyotypes will detect abnormal chromosomes in about 644 newborns among every 100,000 births (Lebo et al, 1992). Banded chromosome analysis is time-consuming and requires considerable training and expertise from growing the cells and preparing slides of well separated, banded chromosomes, to recognizing and analyzing spreads of randomly mixed metaphase banded chromosomes from selected cells for whole and partial chromosome abnormalities. Nevertheless, chromosome banding identifies only about half of all genetic abnormalities because the limit of light microscope resolution is on the order of 5,000,000 basepairs of DNA (5 Mb spanning an average of 50 genes) that must be modified in order to detect a change in the chromosome banding pattern. In contrast, molecular testing can use sampled cells that have not grown outside the body, complete analysis in hours rather than days, and distinguish the modification of a single basepair change or quantify the number of target gene sequences that may have changed within a normal appearing banded chromosome. With the exception of chromosome banding, a single format has not been applied successfully to genome-wide screening.

Initially we conceived and developed a screening test for aneuploidy of five chromosomes (13, 18, 21, X, and Y) that result in 95% of chromosomally abnormal newborns (Lebo et al, 1992). This test has been modified by other investigators to enumerate chromosome 13 and chromosome 21 independently and with simultaneous commercialization and wider testing validation by Vysis has received FDA approval. Today this is used for late gestation fetuses to determine rapidly whether a fetus with an abnormal ultrasound has one of these viable chromosome aneuploidies in order to optimally plan delivery (Lapidot-Lifson et al, 1996) and to obtain a rapid result for earlier gestation pregnancies undergoing triple screen analysis. G-banded karyotypes are still completed routinely on all sampled fetal cells (amniocytes or chorionic villus cells).

Considering these developments, our initial patent application suggested selecting carefully chosen genome-wide chromosome sites to be tested for aneuploidy in order to detect the largest proportion of chromosome rearrangements resulting in partial or full chromosome aneuploidy, and to test for all additional submicroscopic and microscopic deletions that commonly result in genetic disease because this would be a more rapid test that detected a larger number of abnormal fetuses than Giemsa-banded karyotyping (Lebo et al., Provisional 60/161857). As we have continued to work on this approach, we designated the most common gene mutations to be tested simultaneously to detect the largest number of genetic abnormalities possible in a single test on a minimal size testing format.

More recently Snijders et al., (2000) applied CGH to segments of chromosomes at 1 Mb regions in order to detect aneuploid (absence of two) copies of each location reflecting chromosome rearrangement. This requires >2,000 sites to test the 3,000,000,000 basepair haploid human genome at ˜1 megabase intervals. Two difficulties were not anticipated using this approach: (1) the greater the number of sites tested, the greater the likelihood that an error will occur given the same error frequency at each tested site, and (2) tested sites were designated according to physical distance rather than selecting genetically important sites that when mutated result in the most common disease-causing mutations. Thus a large proportion of normal patients tested at these >2000 sites have deleted chromosome regions that merely reflect normal polymorphic variability (Alfred Mazzocchi, Vysis Molecular specialist-Midwest, Pers. Comm., August, 2002). Therefore this approach requires determining the normal polymorphic variability in the general population and the restructuring of the sites selected.

The cystic fibrosis gene is mutated by any one of over 1000 mutations carried by 1 in 29 Caucasians. Over two dozen laboratories offer routine cystic fibrosis testing for 12 to 100 cystic fibrosis mutations. The number of mutation tests offered reflect not only the frequency each mutation is found within the tested population but also differences in the laboratory's prior experience in identifying specific cystic fibrosis mutations, and the likelihood of test referral from genetics professionals based upon the number of tested mutations. The economic principle of “diminishing returns” states that when any factor is increased while other factors are held constant in amount, the gain in benefit beyond a certain point will diminish for each additional unit of resources invested. Given an ever larger number of mutations tested and an equal probability of error on each single mutation test provided, the probability of laboratory error could exceed the likelihood of finding any tested mutation. Given that most cystic fibrosis mutations are extremely rare and the likelihood of making a laboratory error may exceed the likelihood of finding a rare mutation, the American College of Medical Genetics committee on cystic fibrosis testing decided that testing the 25 mutations found in >0.1% of the cystic fibrosis mutant alleles in all Caucasions is to be considered standard-of-care for all testing laboratories. Selecting these 25 mutations opened the opportunity for the best laboratories to test other common disease gene mutations that detect many more abnormal alleles than tests for very rare alleles at one gene site. Reflex gene mutation or sequencing tests provide the opportunity to complete the most reliable diagnoses in higher-risk patient populations.

The following references are relevant as background to the present invention:

Lebo R V, Saiki R K, Swanson K, Montano M A, Erlich H A, Golbus M S: Prenatal diagnosis of □-thalassemia by PCR and dual restriction enzyme analysis. Hum Genet 85:293-299, 1990.

Lebo R V, Lynch E D, Golbus M S, Yen P H, Shapiro L: Prenatal in situ hybridization test for deleted steroid sulfatase gene. Am J Med Genet 46(6):652-658, 1993a.

Lebo R V, Martelli L, Su Y, Li L-Y, Lynch E, Mansfield E, Pua K, Watson D, Chueh J, Hurko O: Prenatal diagnosis of Charcot-Marie-Tooth disease Type 1A by multicolor in situ hybridization. Am J Med Genet 47(3):441-450, 1993b.

Mansfield E S. Diagnosis of Down syndrome and other aneuploidies using quantitative polymerase chain reaction and small tandem repeat polymorphisms. Hum Molec Genet 1992;2:43-50.

Pinkel D, Albertson D, Gray J W, Comparative fluorescence hybridization to nucleic acid arrays. U.S. Pat. No. 5,830,645. Nov. 3, 1998.

Riordan et al., “Identification of the cystic fibrosis gene: cloning and characterization of complementary DNA. Science 245:1066-1073, 1989.

Snijders A M, Hindle A K, Segraves R, Blackwood S, Myambo K, Yue P, Zhang X, Hamilton G., Brown N, Huey B, Law S, Gray J, Pinkel D, Albertson DG. Quantitative DNA copy number analysis across the human genome with ˜1 megabase resolution using array CGH. Am J Hum Genet 67(4) 31, 2000.

Wyandt H, Lebo R, Yosunkawa Fenerci E, Sadhu D N, Milunsky J. Molecular and cytogenetic characterization of duplication/deletion in a supernumerary der(9) resulting in 9p trisomy and partial 9q tetrasomy. Am J Med Genet 93:305-312, 2000.

Lebo R V, Flandermeyer R R, Lynch E D, Lepercq J A, Diukman R, Golbus M: Prenatal diagnosis with repetitive in situ hybridization probes. Am J Med Genet 43:848-854, 1992.

Gardner R J M and Sutherland G R. Chromosome Abnormalities and Genetic Counseling. Oxford Monographs on Medical Genetics No. 29, Oxford University Press, 1996, pp. 87-89.

Milunsky J M, Lebo R V, Ikuta T, Maher T A, Haverty C E, Milunsky A. Mutation Analysis in Rett Syndrome. Genetic Testing 5(4):321-325, 2001.

Herbergs J, Smeets E, Moog U, Tserpelis D, Smeets H. MECP2 mutation analysis and genotype/phenotype correlation in 26 Dutch Rett syndrome patients. Am J Hum Genet 69(4):306, 2001.

Lebo R V, Flandermeyer R R, Lynch E D, Lepercq J A, Diukman R, Golbus M: Prenatal diagnosis with repetitive in situ hybridization probes. Am J Med Genet 43:848-854, 1992.

Milunsky J M, Lebo R V, Ikuta T, Maher T A, Haverty C E, Milunsky A. Mutation Analysis in Rett Syndrome. Genetic Testing 5(4):321-325, 2001.

SUMMARY OF THE INVENTION

This invention increases the proportion of informative tests for whole or partial chromosome aneuploidy or gene aneuploidy over current methods by using quantitative gene region analysis to (1) unambiguously characterize aneuploidy of chromosomes 13, 18, 21, X and Y that result in a majority of the phenotypic chromosome abnormalities in fetuses and newborns, (2) expand testing to detect other microscopic or submicroscopic partial chromosome imbalances in 30 additional chromosome regions, (3) test genetic diseases resulting from unique gene aneuploidy including, and (4) to readily add testing for the most common gene mutations in the patient's ancestral population. Detecting the second category of gene imbalance will increase the frequency of prenatal chromosome abnormalities that are detected rapidly in Category 1 from 95% of phenotypically significant chromosome abnormalities in newborns (Lebo et al, 1992) to 98%, while also adding category (3) will provide a total pickup of 102% of the number detected by current Giemsa-banded chromosome analysis. This includes testing for the 7 common deleted dystrophin gene regions to detect about 60% of the dystrophin gene mutations in affected male fetuses found at a frequency of about 1 in 20,000 live births in families with no prior family history with the ability to determine these results from a direct fetal cell sample without cell culture, DNA analysis is predicted to be more clear-cut than the rapid screening Combined interphase in situ hybridization test and when sufficiently reliable is likely to replace karyotyping as the screening test of choice. The fourth test category will optimize genome-wide screening for the most common genetic disease mutations in the target population. Combining the most common chromosome abnormalities that can be tested with the most common gene mutations will detect even more major genetic abnormalities than standard amniocentesis. At the same time, testing for other common mutations like the 8 common Rett gene point mutations will detect two-thirds of the viable fetuses with Rett syndrome which affects about 1 in 12,000 (Herbergs et al, 2001) with about 99% of affected fetuses carrying de novo mutations (Milunsky et al, 2001). Adding 8 Rett sites to be tested will detect 103% of abnormalities detected by G-banded karyotypes and require testing 46 selected assays around the genome. Selection of the sites to be tested can be modified depending upon new data and the target population and the frequency of each mutation compared to other individual mutations within the population. Individual mutation frequencies are calculated according to the frequency of the genetic disease and the frequency that each mutation contributes to the total number of mutations that result in that disease. Simultaneously testing these categories of genetic diseases will provide the most optimal genetic screening tool for fetuses, newborns, pregnant couples, and aging patients undergoing routine physical examinations in order to provide optimal lifelong care. As these tests become less expensive and more inclusive, formats can be tailored to different populations throughout the world where specific genetic diseases are common that are not screened in other populations.

With the present invention, the construction and application of a genome-wide screen that selects and tests the most common chromosomal regions that when unbalanced result in a viable abnormal newborn. Unbalanced gametes and zygotes result from whole chromosome aneuploidy (abnormal number), unbalanced translocations (unbalanced reciprocal chromosome segment switches), deletions, insertions, marker chromosomes (extra partial chromosomes), and more complex rearrangements. Balanced gametes with the correct total gene number result from balanced translocations and inversions (changing the order of some genes within the chromosome). Testing 27 selected chromosome regions that when unbalanced most commonly result in viable abnormal newborns would identify an estimated 98% of chromosome rearrangements that result in phenotypic abnormality in newborns. Site selection within these chromosome regions also depends upon the means used to test the number of DNA targets i.e. (1) polymorphisms tested by hybridization to target DNA sequences or observed after visualization to distinguish quantity between unique polymorphic (normally variable) alleles, or (2) hybridization to large nonvariable target DNA sequences. Sites are specifically avoided that encode a normal phenotype even when unbalanced to simplify test interpretation and minimize reflex testing and turn around time. Selection of the chromosome sites will be according to: (1) the published common aneuploid chromosome regions resulting in abnormal newborns, (2) additional sites that increase the frequency of pickup of abnormality according to the limit of the assay format used, and (3) the common gene mutation and deletion sites of the most common genetic diseases tested in the patient's ancestral population.

Herein we present one preferred genome-wide testing embodiment with a core of 27 selected chromosome sites for prenatal testing to detect about 98% of the phenotypical abnormal newborns among the 644 chromosome abnormalities found per 1,000,000 newborns. Another 11 common submicroscopic deletion/duplication sites including Dystrophin, SNRPN, PMP22 and ELN gene sites to be tested (38 total) to detect submicroscopic de novo mutations resulting in identifying 2% more fetuses with a genetic disease than Giemsa-banded karyotyping or quantification of >2,000 evenly spaced cloned genomic sites (Snijders et al, 2000). It has not escaped our attention that although the abnormal neoplastic karyotypes have common chromosome rearrangements related to cell growth that differ entirely from the fetal karyotypes, the same principles of testing selected modified gene sites will also be superior to testing sites selected arbitrarily according to evenly spaced physical locations on the chromosomes. In fact, the evenly spaced format of evenly spaced physical locations on the chromosomes. In fact, the evenly spaced format of Snijders is quite useful in helping to identify gene locations that are commonly mutated in neoplastic progression. However, after these genes have been identified, the most robust tests are of the genes or gene products themselves.

Molecular genetic testing is becoming ever more important in prenatal diagnosis, maternal and newborn screening, screening for genetic disease in symptomatic and at-risk patients, identity and paternity testing, characterizing disease-causing organisms contracted from others or released by terrorists, characterizing recombinant genes in food, confirming the pedigrees of animals or plants, and identifying criminals. Currently greater than 800 molecular genetic tests are offered in laboratories around the world. Typically each test is offered individually while multiple required tests might need to be submitted to multiple laboratories to be completed. Offering a screening test for the most common abnormal alleles is the most efficacious method of screening patients in the population and designating which patients should be tested by the more complex kayotyping and specific disease tests offered in many laboratories.

A corollary to this approach is that screening any group of at-risk individuals for molecular genetic diseases should be based upon the frequency of the common gene mutations in the population. When the frequencies are determined by multiplying the frequency of the disease times the frequency of mutations for each specific DNA alteration, these frequencies can be listed from most common to least common. Then any molecular genetic test format that is developed can simply move down the list as far as the number of mutations that can be tested reliably, simply, and cost effectively given the test format. This will screen for the largest number of genetic disease genes. The list will vary according to the age, clinical status, and race of the at-risk patient being tested. For all mutations found in the heterozygous state for autosomal recessive genetic diseases, disease-specific reflex tests would be offered.

The present invention also contemplates the use of kits that contain multiple allelic site primer sequences in a few tubes that can be aliquoted and tested as a multiplex test. This provides a convenient way of employing the genome-wide screens of the present invention.

Definitions

To aid in understanding the invention, several terms are defined below. “PCR amplification reaction mixture” refers to an aqueous solution comprising the various reagents used to amplify a target nucleic acid. These include: enzymes, aqueous buffers, salts, target nucleic acid, and deoxyribonucleoside triphosphates. Depending upon the context, the mixture can be either a complete or incomplete amplification reaction mixture and the primers may be a single pair or nested primer pairs.

“PCR amplification reagents” refer to the various buffers, enzymes, primers, deoxyribonucleoside triphosphates (both conventional and unconventional), and primers used to perform the selected amplification procedure.

“Amplifying” or “Amplification”, which typically refers to an “exponential” increase in target nucleic acid, is being used herein to describe both linear and exponential increases in the numbers of a select target sequence of nucleic acid.

“Bind(s) substantially” refers to complementary hybridization between an oligonucleotide and a target sequence and embraces minor mismatches that can be accommodated by reducing the stringency of the hybridization media to achieve the desired priming for the PCR polymerases or detection of hybridization signal.

The phrase “biologically pure” refers to material that is substantially or essentially free from components which normally accompany it as found in its native state. For instance, affinity purified antibodies or monoclonal antibodies exist in a biologically purified state.

As used to refer to nucleic acid sequences, the term “homologous” indicates that two or more nucleotide sequences share a majority of their sequence. Generally, this will be at least about 70% of their sequence and preferably at least 95% of their sequence. Another indication that sequences are substantially homologous is if they hybridize to the same nucleotide sequence under stringent conditions (see, e.g., Sambrook et al., Molecular Cloning—A Laboratory Manual, Cold Spring Harbor Laboratory, Cold Spring Harbor, N.Y., 1985). Stringent conditions are sequence-dependent and will be different in different circumstances. Generally, stringent conditions are selected to be about 5.degrees C. lower than the thermal melting temperature (Tm) for the specific sequence at a defined ionic strength and pH. The Tm is the temperature (under defined ionic strength and pH) at which 50% of the target sequence hybridizes to a perfectly matched probe. Typically, stringent conditions will be those in which the salt concentration is at least about 0.2 molar at pH 7 and the temperature is at least about 60. degrees C.

As used to refer to proteins or polypeptides, the term “homologous” is meant to indicate two proteins or polypeptides share a majority of their amino acid sequences. Generally, this will be greater than 90% and usually more than 95%.

“Hybridizing” refers to the binding of two single stranded nucleic acids via complementary base pairing.

“Nucleic acid” refers to a deoxyribonucleotide or ribonucleotide polymer in either single- or double-stranded form, that unless otherwise limited also encompass known analogs of natural nucleotides that can function in a similar manner as naturally occurring nucleotides.

“Nucleotide polymerases” refers to enzymes able to catalyze the synthesis of DNA or RNA from a template strand using nucleoside triphosphate precursors. In the amplification reactions of this invention, the polymerases are template-dependent and typically add nucleotides to the 3′-end of the polymer being synthesized. It is most preferred that the polymerase is thermostable as described in U.S. Pat. No. 4,889,819, incorporated herein by reference.

The term “oligonucleotide” refers to a molecule comprised of two or more deoxyribonucleotides or ribonucleotides, including primers, probes, nucleic acid fragments to be detected, and nucleic acid controls. The exact size of an oligonucleotide depends on many factors including its ultimate function or use. Oligonucleotides can be prepared by any suitable method, including, cloning and restriction enzyme digestion of appropriate sequences and direct chemical synthesis by a method such as the phosphotriester method of Narang et al., 1979, Meth. Enzymol. 68:90-99; the phosphodiester method of Brown et al., 1979, Meth. Enzymol. 68:109-151; the diethylphosphoramidite method of Beaucage et al., 1981, Tetrahedron Lett. 22:1859-1862; and the solid support method of U.S. Pat. No. 4,458,066, each of which is incorporated herein by reference.

The term “primer” refers to an oligonucleotide, whether natural or synthetic, capable of acting as a point of initiation of DNA synthesis under conditions in which synthesis of a primer extension product homologous to a nucleic acid strand is induced, i.e., in the presence of four different nucleoside triphosphates and an agent for polymerization (i.e., DNA polymerase or reverse transcriptase) in an appropriate buffer and at a suitable temperature. A primer is preferably a single-stranded oligodeoxyribonucleotide. The appropriate length of a primer depends upon its intended use but typically ranges from 15 to 70 nucleotides. Short primer molecules generally require cooler temperatures to form sufficiently stable hybrid complexes with the template. A primer need not reflect the exact sequence of the template but must be sufficiently complementary to hybridize to a template.

The term “primer” may refer to more than one primer, particularly in the case where there is some ambiguity in the information regarding one or both ends of the target region to be amplified. For instance, if a region shows significant levels of polymorphism or mutation in a population, mixtures of primers can be prepared that will amplify alternate sequences. A primer can be labeled, if desired, by incorporating a label detectable by spectroscopic, photochemical, biochemical, immunochemical, or chemical means. For example, useful labels include p32, fluorescent dyes, electron-dense reagents, enzymes (as commonly used in an ELISA), biotin, or haptens and proteins for which secondary labeled antisera or monoclonal antibodies are available. A label can also be used to “capture” the primer, so as to facilitate the immobilization of either the primer or a primer extension product, such as amplified DNA on a solid support.

“Probe” refers to an oligonucleotide which binds through complementary base pairing to all or part of a target nucleic acid. It will be understood by one of skill in the art that probes will typically substantially bind target sequences lacking complete complementarity with the probe sequence depending upon the stringency of the hybridization conditions. The probes are preferably directly labeled as with isotopes or indirectly labeled such as with biotin to which an avidin or streptavidin complex may bind later. By assaying for the presence or absence of the probe, one can detect the presence or absence of the target.

“Recombinant” when referring to a nucleic acid probe indicates an oligonucleotide that is free of native proteins and nucleic acid typically associated with probes isolated from the cell, which naturally contains the probe sequence as a part of its native genome. Recombinant probes include those made by amplification such as PCR and genetic cloning methods where bacteria are transformed or infected with the recombinant probe.

The term “reverse transcriptase” refers to an enzyme that catalyses the polymerization of deoxynucleoside triphosphates to form primer extension products that are complementary to a ribonucleic acid template. The enzyme initiates synthesis at the 3′-end of the primer and proceeds toward the 5′-end of the template until synthesis terminates. Examples of suitable polymerizing agents that convert the RNA target sequence into a complementary, DNA (cDNA) sequence are avian myeloblastosis virus reverse transcriptase and Thermus thermophilus DNA polymerase, a thermostable DNA polymerase with reverse transcriptase activity marketed by Perkin Elmer Cetus, Inc.

As used herein, the term “sample” refers to a collection of biological material from an organism containing nucleated cells. This biological material may be solid tissue as from a fresh or preserved organ or tissue sample or biopsy; blood or any blood constituents; bodily fluids such as amniotic fluid, peritoneal fluid, or interstitial fluid; cells from any time in gestation including an unfertilized ovum or fertilized embryo, preimplantation blastocysts, or any other sample with intact interphase nuclei or metaphase cells no matter what ploidy (how many chromosomes are present). The “sample” may contain compounds which are not naturally intermixed with the biological material such as preservatives anticoagulants, buffers, fixatives, nutrients, antibiotics, or the like.

The terms “allele-specific oligonucleotide” and “ASO” refers to oligonucleotides that have a sequence, called a “hybridizing region,” exactly complementary to the sequence to be detected, typically sequences characteristic of a particular allele or variant, which under “sequence-specific, stringent hybridization conditions” will hybridize only to that exact complementary target sequence. Relaxing the stringency of the hybridizing conditions will allow sequence mismatches to be tolerated; the degree of mismatch tolerated can be controlled by suitable adjustment of the hybridization conditions. Depending on the sequences being analyzed, one or more allele-specific oligonucleotides may be employed. The terms “probe” and “ASO probe” are used interchangeably with ASO.

A “sequence specific to” a particular target nucleic acid sequence is a sequence unique to the isolate, that is, not shared by other previously characterized isolates. A probe containing a subsequence complementary to a sequence specific to a target nucleic acid sequence will typically not hybridize to the corresponding portion of the genome of other isolates under stringent conditions (e.g., washing the solid support in 2×SSC, 0.1% SDS at 70. degrees C.).

“Subsequence” refers to a sequence of nucleic acids that comprise a part of a longer sequence of nucleic acids.

The term “target region” refers to a region of a nucleic acid to be analyzed and may include polymorphic or mutation sites.

The term “thermostable polymerase enzyme” refers to an enzyme that is relatively stable when heated and catalyzes the polymerization of nucleoside triphosphates to form primer extension products that are complementary to one of the nucleic acid strands of the target sequence. The enzyme initiates synthesis at the 3′-end of the primer and proceeds toward the 5′-end of the template until synthesis terminates. A purified thermostable polymerase enzyme is described more fully in U.S. Pat. No. 4,889,818, incorporated herein by reference, and is commercially available from Perkin-Elmer Cetus Instruments (Norwalk, Conn.). thermostable polymerase” typically can resist repeated heating to remain active through multiple DNA denaturation cycles.

BRIEF DESCRIPTION OF THE DRAWINGS

Other features and advantages of the invention will be apparent from the following description of the preferred embodiments thereof and from the claims, taken in conjunction with the accompanying drawings, in which:

FIG. 1 shows the standard chromosome bands from which the gene locations were selected (reported in ISCN 1985, Report of the standing committee on Human Cytogenetic Nomenclature, pp. 48-57, 1985).

DESCRIPTION OF A PREFERRED EMBODIMENT

Described herein are methods to optimally construct nucleic acid kits to test for target copy number of the selected gene regions in the designated chromosome bands and in common genetic disease genes as well as common gene mutations in common genetic disease genes that together are required for normal growth and development. When genes in these banded chromosome regions are abnormal in number or sequence, viable abnormal fetuses may live to term and beyond.

Conducting a DNA test that identifies more fetal abnormalities than Giemsa-banded karyotyping requires searching the entire genome for important chromosome regions that when abnormal result in viable newborns. The most readily apparent abnormalities involve differences in the number of whole chromosomes or chromosome regions that result when one of a very large majority of chromosome rearrangements occurs. Therefore quantification of the relative number of target sequences is required to distinguish the normal autosomal and pseudoautosomal diploid two copies from haploid, male, sex chromosome copies and all other abnormal copy number in every cell: 0, 1, 3, 4, >4. Mosaic copy number when detected is also of importance in symptomatic patients with abnormal chromosome rearrangements and very important in oncology patients.

Therefore DNA analysis must not only identify but quantify the number of target alleles at any single site selected for analysis. The most reliable method is to be selected to determine gene copy number. Several methods have been used to quantify target genes: (1) restriction enzyme analysis to give known length restriction fragments for each allelic type (Lebo et al., 1990), fluorescence in situ hybridization to interphase nuclei or metaphase chromosomes to detect gene deletion (Lebo et al, 1993a) or duplication (Lebo et al., 1993b), quantitative PCR (QPCR; Mansfield, 1992), comparative genomic hybridization to metaphase chromosomes or nucleic acid arrays (Pinkel et al, 1998), and Invader technology (Third Wave Technologies) with 4 colors on one spot. The reliability of any quantification method can be optimized by adding more colors, more independent assays, and more normal and abnormal controls. Furthermore, while interlocus comparison has been sufficiently reliable for QPCR analysis (Mansfield, 1992), testing distinguishable polyorphic alleles simultaneously will further enhance reliability as the same flanking sequences are being tested simultaneously. No matter the method selected, the final result must be highly reliable and reflex tests must be easy and rapid because a single reflex test doubles the assay time. On the order of 50 tests are the minimal number required to offer a robust genetic test with high pickup rate of genetic abnormalities in prenatal samples. This number will vary depending upon the age of the patient tested, the number of appropriate tests, and whether the tested tissue is derived from a suspected or known neoplastic tissue. Of the previously mentioned current protocols, restriction enzyme analysis is too time consuming and in situ hybridization is time and labor intensive, leaving QPCR, CGH, and Invader.

The well characterized categories of chromosome abnormalities and their relative frequencies in newborns has been reported (refer to Lebo et al, 1992, Table III). The relative numbers of phenotypic abnormalities involving rearrangements other than abnormal chomosome number was divided into high risk (>10% of anatomic malformations and anatomic delay), and Low Risk (5-10% risk). Given that 2% of fetuses in the high risk group have unbalanced translocations, then an estimated 97% of these abnormalities would be detected by testing 26 chromosome sites: 1q, 2p, 2q, 3p, 4p, 5p, 5q, 6q, 7p, 8p, 8q, 9p, 10p, 10q, 11q, 12p, 14q, 15q, 16p, 17q, 18p, 18q, 19q, 20p, 21q, and 22q (Table 1). [Note: This 97% is estimated by assuming the values like <1.3 for 1qter (q23-32) is=1.3 and that recombination occurs equally in the distal arms of different chromosomes.] Although some deletions will be tested by quantification of these 26 chromosome sites, the 1% of deletions with high risk of abnormality were calculated from Table III as though all were missed. In the LOW risk category III In Table III, the risk of abnormality is 7% of all chromosome abnormalities and the likelihood of anatomic malformation or developmental delay is 5-10%. Because this category of chromosome abnormalities would have been missed completely, we calculated the likelihood of not detecting these abnormalities as 7%×7.5%=0.525%. The marker and insertion chromosomes have been combined in Table III because these categories were combined when merging the data by Vogel and Motulsky (1986) and Nielsen and Sillisen (1975). Assuming that each category contributes to half of the 11%, then 5.5% of insertions will have about a 7.5% risk of abnormality [5/5%×7.5%=0.4125%. Furthermore, half of a series of 50 marker chromosomes were dup (15) and 12% were iso(12p) and iso(18p). Thus These abnormalities would be detected by the SNRPN gene probes used to test Prader-Willi deletions and the 12p and 18p loci tested in the above list used to search for unbalanced translocations: [5.5%×62%×7.5%=0.255%]. Therefore the total percent of abnormal chromosome rearrangements detected by quantification of 27 loci (26 above plus the 1 SNRPN gene, Table 1) would be 1.94%. Overall, this test would pick up 518 newborns with phenotypically abnormal chromosome rearrangements in 100,000 newborns and miss 13.

In contrast, adding 7 sites in the Duchenne muscular dystrophy gene would detect 5 de novo mutations in 100,000 newborns (Table 1); quantifying the SNRPN gene locus would detect the 70% of deletions in the Prader-Willi and Angelman Syndromes and detect 5 additional de novo mutations in 100,000 newborns, testing the PMP22 gene copy number would detect the 4 de novo CMTlA mutations and any HNPP mutations, testing the ELN gene site would detect the 10 Williams syndrome newborns, while testing the SRY gene site and the AZF gene on Yq11.2 would determine sex and detect females with a high risk for gonadal cancer and a portion of azoospermic males. Excluding the Y chromosome loci, these additional 11 sites (added to 27 above, Total=38) would determine sex and detect 24 additional newborns with a major genetic abnormality (about twice the 13 that were missed in the rare abnormal chromosomal category above).

Additional selective gene sites can be added that were not mentioned like the DiGeorge syndrome critical region on chromosome band 22q11 and other common gene or chromosome deletion syndromes as these are characterized. Furthermore, additional chromosome sites can be characterized selectively as more information is collected. For instance, 8 more sites (3q, 4q, 6p, 7q, 9q, 11p, 13q, and 17p) to pick up the other reported viable unbalanced translocation sites affecting an estimated 3% of the newborns with unbalanced translocations with this entire class of chromosome rearrangements representing 2% of all abnormal chromosome rearrangements (about 1 per 300,000 newborns).

The sites to be tested are all important in development as mutations at these sites result in genetic disease. These tested sites may be modified according to the population to be tested and the additional data gathered about the frequencies of mutations in disease-causing mutant genes in the same chromosome bands, or whether one is screening oncology patients likely to have mutations in oncogenes. Nevertheless, the principle of selecting genetically important sites for directing development of or maintaining normal tissues remains constant.

Some genetic diseases are common in worldwide populations like Rett syndrome with an estimated frequency of 1/10,000 to 1/15,000. As 8 point mutations account for about 66% of all Rett gene mutations, testing for these 8 additional sites (38 above plus 8=46 loci) would detect de novo mutations in 8 fetuses. Together this would detect 32 fetuses with de novo mutations that would not have been tested otherwise.

Depending upon the region of the world from which the patient's ancestors were derived, the screening test would also be optimized for the common genetic disease mutations to be tested. For instance, the sickle cell anemia mutation is common in African blacks, the beta thalassemia mutations are common in the Mediterranean, the alpha and beta-thalassemia mutations are common in Southeast Asia, hemophilia is common in Korea, and cystic fibrosis is common in Caucasians. For instance, testing for the common ΔF508 mutation locus in the cystic fibrosis transmembrane receptor gene (Riordan et al, 1989) will detect 70% of cystic fibrosis mutations in the Caucasian population and will detect at least one mutation in 91% of fetuses affected with cystic fibrosis. Therefore adding this single point mutation test to the other sites tested will detect 31 fetuses or newborns with cystic fibrosis out of 100,000 tested.

Different disease tests should be completed at different stages of the life cycle. Huntington disease testing has been reserved for patients requesting the test who are over 21 years of age. The number of couples requesting prenatal diagnosis are rare because the at-risk parent generally does not want testing prior to developing symptoms, perhaps because no cure is available. In contrast, testing patients is becoming more common for increased risk for pulmonary emboli, colon cancer, breast cancer, or other genetic diseases for which medical interventions exist that are more effective or likely to be applied regularly when the increased risk is known. These tests will become part of panels recommended for patients at different stages of their life cycle.

One method to quantify selected target loci is to do quantitative PCR (QPCR) with internal control sites to determine the number of alleles at each tested site. Quantitative PCR to detect the number of alleles is most effective when highly polymorphic allelic sites are tested and the quantities of two or more different allelic products are compared (Wyandt et al., 2000). In Wyandt et al. the amount of product is determined by densitometry scanning of X-ray film exposed to P³²-labeled PCR product. Four different alleles instead of two were demonstrated by three peaks, one of which had twice the product as the other two, to give a pattern representing four different alleles. Four allelic targets are unusual. Most sites normally have two alleles, with one allele following deletion and three alleles following duplication. If one target had three copies of alleles of three different lengths, the products would give three different length peaks with equal area under each peak. With three alleles and two different lengths the result would be two different peaks, one of which had twice the area under it as the adjacent peak. With two alleles that were polymorphic either two equal size different length adjacent peaks would be scored or one peak with twice the area under the peak reflecting two alleles. With one allele, a single peak would always appear with an area under the peak reflecting one allele equivalent. Testing the quantity of PCR amplified product for each allele is most readily done when at least two different alleles that can be separated and quantified by the assay exist at the target sequence.

Test Procedure

When testing highly informative polymorphic loci, the frequencies of detecting more than one allele are increased considerably. In order to find polymorphic sites in the region of genetic disease genes, identify the largest sequenced DNA fragment containing the gene. Then search the database for the most highly polymorphic sites in the gene region of interest including in overlapping sequenced DNA fragments. The most highly polymorphic loci in the area would be listed in descending order beginning with the highest heterozygosity index. The heterozygosity index of each polymorphic site indicates the proportion of all normal individuals tested that are anticipated to have two different alleles, one on each chromosome, at the tested locus. At normally diploid loci, Het.=1−[(a1)2+(a2)2+ . . . +(an)2]

where Het (heterozygosity index) equals the predicted frequency of individuals with different alleles at this locus based upon the observed allele frequencies for each polymorphic length of alleles a1, a2, . . . an with the original sample series tested. For instance, if the calculated heterozygosity index is 0.8, an estimated 80% of randomly tested normal individuals will have two different length alleles at this location. The most reliable result will be obtained by combining all reported data at each locus. Each laboratory may modify the frequencies used for calculations depending upon the results obtained in a series of patients tested by that laboratory. After the most informative loci are ordered in descending order of heterozygosity indices down to perhaps 0.7 or 0.65, all available cytogenetic locations and or centimorgans from the end of the short arm or from the centromere are added to each locus on the list. Next a sufficient number of loci are chosen to be informative at a preselected frequency to determine whether each tested chromosome region has the normal number of copies or an aneuploid copy number. For instance, testing 4 loci each with a heterozygosity index of 0.8 in the same chromosome region will give at least two loci with two different allelic lengths in 96% of all normal individuals tested (Derived from Appendix 1).

The criteria for distinguishing normal from aneuploid copy number are anticipated to be different for the different chromosomal loci tested because the frequency of different comparable outcomes will vary according the individual heterozygosity indices at the loci tested and the number of loci tested. Thus an optimal test can be designed according to the ultimate application of the test and the reliability required from the result. Distinguishing trisomy from two copies will give at least two different alleles with a 2:1 ratio in a larger proportion of cases than a diploid chromosome region. At trisomic loci, Het.=1−[(a1)3+(a2)3+ . . . +(an)3]

where Het equals the predicted frequency of individuals with three alleles of at least two different sizes at this locus based upon the observed allele frequencies for each polymorphic length of alleles a1, a2, . . . an with the original sample series tested (See Appendix 1). Therefore a locus with a heterozygosity index of 0.8 in a normal individual will have at least two different length alleles in an estimated 96% of individuals tested with three copies of this locus. Thus the effort required to identify polymorphic sites with the highest heterozygosities in diploid humans is well worth the effort (Appendix I).

In contrast, distinguishing aneuploidy in the sex chromosomes will require testing loci on two different chromosomes X and Y and comparing these results to autosomal and pseudoautosomal control loci. The origin of two or more sex chromosomes is anticipated to give polymorphic site discrimination the same as for two or more autosomes (chromosomes 1 to 22) as described above. In contrast, the presence of 2 or more Y chromosomes in a human fetus is anticipated to come from two identical copies of the Y chromosome from the father. The presence of a single Y chromosome can be detected easily by PCR amplifying the SRY gene and/or the ZFY gene and the amelogenin Y gene. Distinguishing more than 1 Y chromosome copy from 1 Y chromosome copy can be done by comparing the peak height of a unique PCR amplified site with an autosomal site. Further confirmation of more than 1 Y chromosome can also be obtained by comparing the number of PCR amplified sites in the pseudoautosomal regions of the end of the short arms of both the X and Y chromosomes where identity between these chromosome regions is maintained by meiotic recombination.

Determining aneuploidy with a reliability sufficient to terminate a pregnancy will require highly reliable test results. A first round screening test for aneuploidy may require a second round QPCR test to confirm suspicious . Alternatively, a different test method that alone may be less reliable may along with the first test still exceed the reliability of all existing prenatal tests except cytogenetics. Thus a second tier of tests that characterize additional sites in the same chromosome region can be used to retest genomic regions that appear to be abnormal without sufficient corroborating evidence to make an irreversible clinical decision. For instance, terminal deletion of the long arm of chromosome 16 may be evident from two different polymorphic loci that each amplify half as well as the other autosomal loci. Nevertheless, amplification of two or more additional loci in this chromosome region may need to be compared to a coamplified normal chromosome region in order to confirm the diagnosis.

Characterizing the most common chromosome aneuploidies unambiguously is the first priority in prenatal testing because these are the most common chromosome abnormalities. Three other laboratories have reported that testing a very highly polymorphic locus gives three different alleles in a majority of cases of trisomy tested. Still, testing a single chromosome 21 region is anticipated to give at most two different alleles in a substantial proportion of all cases because nondisjunction can occur either in Meiosis I or in Meiosis II. Therefore testing a proximal chromosome locus will usually give only two different parental chromosome arms in about 80% of trisomy 21 fetuses because two identical chromosome regions are passed on by the maternal gamete. However, because recombination occurs in each chromosome pair at meiosis to prevent nondisjunction in most meioses, the distal chromosome region will have two different parental chromosome regions passed on by the same gamete in these same cases. Therefore testing distal chromosome regions in abnormal embryos that resulted from nondisjunction in Meiosis I will detect three different regions and three different alleles at a proportion of the distal highly polymorphic loci tested. If nondisjunction occurs at Meiosis II, the proximal chromosomal loci will be likely to give three different loci and the distal loci will only two different loci. Therefore these two sets of polymorphic loci can be tested for the 5 most common chromosome aneuploidies, loci near the centromere, and more distal loci on the long arm of each chromosome. When testing a sufficient number of proximal and distal loci, three unique peaks will be observed at one of these loci in nearly every case of trisomy (FIG. 1B). Furthermore, if only two peaks are observed that have been amplified from a trisomic region, a two-fold difference in these peaks (FIG. 1B) at multiple loci is also anticipated to be sufficiently reliable to establish a diagnosis.

After the minimum number of polymorphic loci are selected according to the heterozygosity frequencies and chromosome location in order to obtain a DNA result that is sufficiently reliable, the published PCR amplified primer lengths are then compared at all selected loci so that as many different polymorphic sites can be tested simultaneously as possible with no overlap in allelic fragment lengths. Three to four polymorphic sites can generally be amplified by multiplex PCR in the same tube and incorporated with the same color fluorescent label. These can all be analyzed simultaneously in the same lane of an electrophoresis apparatus that records and quantifies each allelic product like those from Applied Biosystems with four different colors and from Lycor with two different colors. If too many polymorphic sites have the same size range allelic products, new primers can be selected from the surrounding genomic sequence until sufficient additional sites have been multiplexed. These might be obtained from the PCR amplified sequence in the database, from the larger site sequence also in the database, or by using additional laboratory protocols published in standard references.

Three different length alleles at any one site will clearly distinguish trisomy unambiguously. Quantifying two different length polymorphic alleles for two equally amplified products of for products with approximately a two-fold difference in product will be tested on multiple samples (Appendix 1). More loci will need to be tested if only three different allelic peaks are considered to give unambiguous results (Not shown). This approach is anticipated to distinguish mosaic aneuploid locations from maternal contamination, triploidy, and tetraploidy (FIG. 1, C-G). QPCR is anticipated to represent a substantial improvement over interphase whole chromosome in situ hybridization analysis because multiple informative polymorphic amplified allelic sites are anticipated to confirm all test results. When sufficient reliability has not been achieved for any single chromosome location, a backup test to obtain additional polymorphic information from the same chromosome region can be used.

In partial aneuploidy described as Category 2, the aneuploid chromosome regions reported in phenotypically abnormal surviving patients will be tested along with the whole chromosomes that are most frequently aneuploid (Table 4-3, Gardner & Sutherland, 2nd ed, pp. 87-88, 1996.) Additional chromosome regions will be tested to identify marker chromosomes. The number of chromosome regions tested will be increased to characterize the number of aneuploidies desired.

Deletions account for a majority of mutations in about a dozen genetic diseases. Deletion can be distinguished because only 1 allele or target is amplified instead of the usual 2 on autosomes of normal people. This single allelic product can be compared to the multiple other autosomal target products in the same lane of the gel that resolves each PCR product by size. Polymorphic sites are unnecessary, but multiple sites will probably have to be compared to confirm that only 50% of the usual PCR product has been amplified. Therefore no limitation exists as to the number of target sites that can be amplified because none of the targets need to be polymorphic.

In contrast, single gene duplications like the CMTlA gene locus spanning 0.5 to 1.5 Mb of chromosomal target are anticipated to have between 3 and 8 di-, tri-, or tetranucleotide repeat polymorphic sites. Since few of these sites have heterozygosity indices exceeding 0.7, it is anticipated that insufficient data could be obtained upon which to base an irreversible clinical decision. If testing these sites becomes important, additional approaches may need to be added like sequencing sites with single base pair polymorphisms and comparing the relative quantity of alleles amplified from each DNA sample.

Other approaches to quantity PCR products include hybridizing a PCR amplified cocktail to an array of ASO targets bound to a multitargeted microchip and comparing the fluorescence of each microchip address, and quantifying the amount of PCR product at multiple PCR cycles to compare amplification during logarithmic accumulation. Any of these approaches are going to give more reliable results when testing multiple loci. At the time of writing, the most straightforward means to quantify fluorescent products is by gel electrophoresis that records the quantity of each polynucleotide repeat product with a resolution of 1 basepair intervals. TABLE 1 Genetic Disease Loci In Critical Chromosome Regions Chromosome Disease Band Tested Gene Disease Locus Tested Frequency OMIM # 1p36.3 MTHFR Homocystinuria due to MTHFR 236250 deficiency 607093 1q44 CIASI FCAS Muckle-Wells Syndrome N.A. 606416 CINCA Syndrome 2p25 TPO Thyroid Peroxidase Deficiency N.A. 274500 2q37 N.A. UGT1A1 Crigler-Najjar Syndrome, N.A. 606785 Type II Gilbert Syndrome 3p25-p26 VHL Von Hippel-Lindau Syndrome N.A. 193300 3q27 or TP63 Tumor Protein P63 N.A 603273 3q28 LPP Lipoma-Preferred Partner N.A. 600700 4p16.3 or FGFR3 Achondroplasia Huntington 1/20,000 100800 4p16.3 HD Disease 143100 4q35 FSHMD1A Facioscapulohumeral 1/250,000 158900 muscular dystrophy 5p15.2-15.3 MSR Methionine Synthase Reductase N.A. 602568 5q35.3 or FLT4 FMS-Like Tyrosine Kinase N.A. 136352 5q35.2-35.3 FLT4 Ehlers-Danlos Syndrome N.A. 604327 6p25 or FOXC1 Iridogoniodysgenesis Factor N.A. 601090 6p25-p24 F13A1 13 coagulation enzyme N.A. 134570 6q27 TBP Spinocerebellar ataxia 17 N.A. 600075 7p22 MAD1L1 Somatic lymphoma N.A. 602686 7q11.2 ELN Williams Syndrome 1/10,000 194050 130160 7q36 PRKAG2 Wolff-Parkinson-White Syndrome N.A. 602743 8p23 or MCPH1 Microcephaly, autosomal N.A. 607117 8p22 LPL recessive 1 1/10,000 238600 Hyperlipoproteinemia I 8q24.3 ZIP4 Acrodermatitis enteropathica N.A. 607059 9p24.2 PDCD1 Mouse model develops lupus* N.A. 605724 9q34.3 AGPAT2 Berardinelli-Seip N.A. 603100 Congenital Lipodystrophy 1 10p15 GATA3 Hypoparathyroidism, N.A. 131320 sensorineural 10q26 OAT Ornithine Aminotransferase N.A. 258870 deficiency 11p15.5 CDKNC1 Beckwith-Wiedemann Syndrome N.A. 600856 11q24 KCNJ1 Bartter Syndrome, Type 2 N.A. 600359 12p13.3 VWD Von Willebrand Factor Deficiency 1/20,000 193400 12q24.2 TCF1 Diabetes Mellitus high 142410 Transcription Factor 1 13q34 IRS2 Diabetes Mellitus Insulin 600797 receptor substrate 14q32.33 IGHM Agammaglobulinemia N.A. 147020 15q11.2 SNRPN # Prader-Willi Syndrome 1/15,000 176270 UBE3A # Angelman Syndrome 1/15,000 601623 15q26.1 RECQL3 Bloom Syndrome N.A. 604610 16p13.3 HBA1 Alpha Thalassemia (C) 141800 41850 16q24.3 FANCA Fanconi Anemia (D) 227650 17p13.3 LIS1 Miller-Dieker Syndrome (E) 247200 90% deletions 17p11.2 PMP22 CMT1A/HNPP 1/5,000(F) 601097 20% de 162500 novo 17q25.3 HSS Sanfilippo Mucopolysaccharidosis (G) 605270 Type IIIA 252900 18p11.3 TGIF Holoprosencephaly N.A. 602630 18q23 CYB5 Methemoglobinemia N.A. 250790 19p13.3 ELA2 Cyclic Hematopoiesis N.A. 130130 19q13.4 TNNT1 Nemaline myopathy N.A. 191041 20p13 AVP Diabetes Insipidus N.A. 192340 Neurohypophyseal 125700 Arginine Vasopressin 21q22.3 ITGB2 Leukocyte adhesion deficiency N.A. 116920 600065 22q11 DGCR DiGeorge Syndrome N.A. 188400 22q13.3 DIA1 Methemoglobinemia N.A. 250800 Diaphorase Deficiency Xp22.32 STS X-linked ichthyosis 1/5,000 308100 Deletions: 90% Xp22.32-pter SHOX Short Stature Homeo Box N.A. 604271 312865 Xp21.2 DMD Duchenne Muscular Dystrophy 1/4,000 310200 65% deletions, 7 sites, 90%, 1/3 new mutations Xq28 SLC6A8 Creatine deficiency syndrome 300352 X-linked 300036 Yp11.3 SRY Sex-determining region Y 480000 Godndal dysgenesis, XY type Yq11.2 USP9Y Azoospermia 400005

Thus, it can be seen that the objects of the invention have been satisfied by the structure and its method for use presented above. While in accordance with the Patent Statutes, only the best mode and preferred embodiment has been presented and described in detail, it is to be understood that the invention is not limited thereto or thereby. Accordingly, for an appreciation of the true scope and breadth of the invention, reference should be made to the following claims. 

1-51. (canceled)
 52. A method for conducting a genome-wide test of an associated patient for use in detecting genotypic abnormalities, the steps comprising: providing a group of genotypic abnormalities comprising: aneuploidy of chromosomal regions and partial chromosome imbalances and common gene mutations; identifying at least a first characteristic of the associated patient; providing a testing means for determining the presence of one or more of the genotypic abnormalities, wherein the testing means selectively comprises a plurality of nucleic acid primers; selecting a predetermined plurality of nucleic acid primers based upon the at least a first characteristic of the associated patient; providing a sample of DNA from the associated patient; and, simultaneously conducting a quantification test for use in detecting one or more of the genotypic abnormalities.
 53. The method of claim 52, wherein the step of identifying at least a first characteristic of the associated patient, comprises the step of: identifying at least a first demographic characteristic of the associated patient.
 54. The method of claim 52, wherein the step of identifying at least a first characteristic of the associated patient, comprises the step of: identifying at least a first phenotypic characteristic of the associated patient.
 55. The method of claim 52, wherein the step of identifying at least a first characteristic of the associated patient, comprises the step of: identifying one of either the associated patient age or ethnic origin. 